The Inman Aligner: part two

The Inman Aligner: part twoFurther to the article on Inman Aligners in the March issue, Dr Tif Qureshi demonstrates more cases he has performed with exceptional results

As more and more patients opt to have elective cosmetic dentistry procedures, it is important that

all practitioners offer patients viable alter-natives as a routine part of their diagnosis and treatment planning. This is essential for medico-legal and ethical reasons. Patients presenting to cosmetic dentists with mild, moderate and severely crowded teeth must be given the choice of dealing with their complaint by orthodontic means.

If a patient has individually unblemished, beautiful teeth that are crowded to any de-gree, ideally the optimal treatment is always orthodontic, where no or minimal extrac-tions are performed. This should be relayed to the patient in honest and frank terms, so that if even minimally invasive treatment is undertaken, the patient has given fully in-formed consent.

Patients who present worn, discoloured and chipped teeth who also happen to be suffering from any degree of crowding are often considered ideal instant-veneer cas-es, because of the fact that the colour and shape of the teeth will only be corrected us-ing laminate facings anyway. As a result, the benefits of orthodontics in minimising the amount of preparation needed for veneers, is perhaps not being fully explained. This might be because of an underdeveloped re-

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84 Aesthetic dentistry today July 2008 Volume 2 Number 4

lationship between orthodontists and cos-metic dentists and hence a lack of co-treat-ment planning. It may also be because of an all-or-nothing mentality that leads some practitioners to act rather independently. It may also be that many patients seeking cos-metic dentistry simply rule out any form of complex orthodontics because they do not want to wait that long.

In the case-types described above, how many cosmetic dentists are offering their pa-tients the opportunity to reduce the amount of preparation needed by various degrees when their discoloured/ poorly shaped and crowded teeth are being treatment planned for veneers?

This article is written to outline alterna-tive ways of thinking in cosmetic dentistry that can help us de-radicalise or even avoid preps in easy and difficult cases. The fol-lowing case highlights one example of many patients who present to me initially wanting quite radical cosmetic dentistry.

Patient A was a 20 year-old student who was very embarrassed about her smile and initially asked for four of her upper teeth be removed and be replaced with a bridge. She had ruled out traditional orthodontic meth-ods because she thought it would take years and she felt her teeth were ‘ugly anyway’.

After discussing all available options

Figure 1: Front View before treatment Figure 2: Close View retracted. Impossible positions for correct emergence profiles

Figure 3: Close view after alignment. Far better posi-tioning for veneer preps

Figure 4: Occlusal view before treatment Figure 5: Stage 1 upper midline expander Figure 6: Standard Upper Inman Aligner

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to her, she decided to have treatment to at least correct the arch form of the up-per teeth before having porcelain veneers placed to minimise the amount of prepa-ration needed. Without doing this, any type of cosmetic dentistry performed with radical preparations would have resulted in aesthetic failure simply because of the diffi-culty in producing realistic emergence pro-files on the lateral teeth. Even with osseous contouring and gingival repositioning, the outcome would have been poor.

As an open bite case on a young adult, midline expansion would be suitable as long as the patient understood that she would need to use a permanent retainer. A traditional midline-expanding device was used for 10 weeks, where the midline screw was half-turned once a week. Then an Upper Standard Inman Aligner was used to push the lateral teeth labially into a more suitable position. Measured interproximal reduction was performed from canine to canine to create space. This took a further six weeks. The patient wore the Inman Aligner as a retainer nightly to stabilise for two months. A wax-up was made on the new arch form incorporating longer more aesthetic teeth.

The teeth were than prepared for ve-neers, but only minimal preps were neces-sary as the teeth were far more favourably aligned. Preps were largely kept within enamel and there were no exposures of pulpal tissue. Eight authentic porcelain veneers were bonded and some bleaching, minimal enameloplasty and direct bond-ing was used to make the lowers look more aesthetic.

Retention consisted of bonding multi-strand stainless steel arch wire on the pala-tal surfaces from upper premolar to premo-lar. The patient also wore a Hawley type retainer nightly.

The Inman Aligner can be used to align teeth in the anterior region only. Limited movement of canines are a restriction, but there is great scope in movement of inci-sors, especially in mild/moderate crowding cases of 3.5 mm or less. The rapid speed of tooth movement is due to the use of nickel-titanium coil springs, which use light pres-sures, but the forces are constant and never let up until the teeth reach their final posi-tion. Conventional orthodontic techniques and invisible braces are equally viable if good communication and treatment plan-ning is shared between the cosmetic dentist and the orthodontist. The Inman Aligner, where suitable, has the advantage of being

fast and highly cost effective. Ultimately it should be the patient’s choice in deciding how much preparation he or she is happy to accept. The cases shown highlight the advantages of aligning before preparing for veneers. More minimal preparations are always more desirable for the patient and the dentist and for a mere three months of extra treatment with a simple removable appliance, this is an option that must be considered for ethical reasons alone.

AcknowledgementCeramic work by A F Knight Ceramics. Aligners constructed by Nimrodental ortho-dontic laboratory.

Dr Tif Qureshi is running a hands-on course certification for the Inman Aligner, with expert assistance from Dr Tim Bradstock-Smith and Dr James Russell. The next available course is on July 19th at the BDA Wimpole Street.

Call Caroline on 0207 255 2559 to reserve your place. See website:

www.straight-talks.com

Figure 7: Upper arch post alignment after 10 weeks Figure 8: Veneers on working model

Figure 9: After alignment and veneer placement Figure 10: After Inman Aligner and veneers front smile view

Figure 11: Before right side view Figure 12: After alignment and veneers left side view

Figure 13: Left side view before treatment Figure 14. Right side view after treatment